CMS Delays 2025 Nursing Home Surveyor Priorities Implementation

The Centers for Medicare & Medicaid Services (CMS) has announced a delay in the implementation of its updated 2025 Mission and Priorities Document (MPD) for nursing home surveyors. Initially scheduled to take effect in February, the revised guidance will now be effective starting March 24, 2025. This extension allows CMS additional time to refine its strategies for assessing compliance with key areas, including staffing levels, antipsychotic medication use, discharge planning, and Payroll-Based Journal (PBJ) reporting.

While the 2025 priorities remain unchanged, this delay provides CMS the opportunity to complete necessary training for surveyors and make technical adjustments to the guidance, particularly in relation to antipsychotic medications, staffing assessments, and PBJ reporting. The updates are extensive, including clarifications on how surveyors will evaluate compliance with regulations concerning admissions, transfers, discharges, unnecessary psychotropic medications, infection control, staffing, and reporting.

CMS has also made significant revisions to the psychotropic medication section of the guidance, further emphasizing efforts to limit the use of chemical restraints and improve the accuracy of diagnoses related to antipsychotic medications. The final version of the updated guidance will be included in Appendix PP of the State Operations Manual, which will be available to surveyors in the Automated Survey Process Environment (ASPEN) system starting March 24.

Nursing homes should remain proactive in reviewing the updated guidance, focusing on areas such as medication management, staffing requirements, PBJ reporting, and accurate documentation, to ensure continued compliance with CMS’s revised standards.

The revised guidance can be accessed here.

Compliance Perspective

Issue

CMS’s 2025 MPD outlines several key enforcement priorities for nursing homes, including the management of antipsychotic medications, involuntary discharges, nurse staffing, and PBJ reporting. With the delay in the implementation of updated guidance until March 2025, nursing homes now have additional time to ensure full alignment with the revised CMS standards. Facilities must prioritize adjustments to policies, staff training, and audits to remain in compliance once the new surveyor priorities take effect. Ensuring these changes are made proactively will help prevent penalties and ensure high-quality care.

Discussion Points

    • Facilities should review and update their policies and procedures to align with CMS’s 2025 enforcement priorities. This includes ensuring compliance with updated diagnostic and reporting requirements for antipsychotic medication use, as well as refining procedures to assess and document resident needs before admission to prevent involuntary discharges. Additionally, staffing procedures should be revised to ensure accurate PBJ reporting and adherence to staffing requirements.
    • Provide training for all relevant staff on the updated CMS requirements. The training should cover proper documentation and management of antipsychotic medications, strategies for assessing and preventing involuntary discharges, and accurate reporting of staffing levels through the PBJ system.
    • Conduct regular audits to assess their current practices related to antipsychotics, nurse staffing, and PBJ reporting. Audits should focus on medication management, discharge procedures, and staffing levels, ensuring any discrepancies are addressed promptly. Auditing processes should also verify that policies and training have been implemented correctly, with corrective actions taken where necessary.

*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*

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